This is a long reply to a post on Wandering Scientist’s blog called Thoughts on Labor, in which she tells her birth story:

I was fascinated by your birth story. You know, I have read so many of them online, but reading yours while I am learning about qualitative research through my fellowship gave me an idea.

You know, I have read so many of them online, but reading yours while I am learning about qualitative research through my fellowship gave me an idea.

One of the reasons I am interested in these birthing issues is I want to examine the power relationships between health care practitioners and women. I am going to use a survey (quantitative) and some in depth interviews (qualitative) with obstetricians in my area. Maybe I could follow up with some qualitative and quantitative research with women regarding birth interventions. Listening to Women has already approached this, but I think it’s mostly quantitative. Maybe I could do some qualitative research on birth stories on the internet to examine women’s perspectives on their interactions (and those of their personal support system, such as your husband in your case) with health care practitioners during the birth process. You did some thoughtful processing of this in your post.

Should a woman need to be so educated on interventions and when they are appropriate that she or someone she brings or hires can run interference to protect her from her paid health care practitioners?
Your husband takes the frequent claim that cesarean is the malpractice preventing option and jumps to the conclusion that it is somehow a safer option and prevents catastrophic problems. However, research usually shows that outcomes are generally worse for the mother, the baby, and future pregnancies with cesarean delivery. There are so many aspects to this I can’t just cite one study. There will be an extensive bibliography on this in my final paper, and you can search my bloghistory or The Unnecesarean for references .
Or, just search the recent contents of the so called Gray Journal (follow the search link and enter this: “Am J Obstet Gynecol”[TA] AND “cesarean”[TIAB] ) and Green Journal (enter: “Obstet Gynecol” [TA] AND “cesarean”[TIAB]). These journals are the bully pulpits of mainstream professional American obstetrics.
Coming to the realization that physicians, nurses, midwives, and even patients with full informed consent and insurance and/or means may make decisions during birth that do not favor the health of the mother or the fetus / neonate is a difficult one for people realize and discuss. My theory is that the interventions chosen by health care practitioners favor the practitioner’s role and make it easier, and that certain risks to the birthing unit are acceptable if it favors the correct direction in the power relationship. Women respond to pregnancy, birth, and subsequent pregnancies and births in a wide variety of ways, and may choose anything from elective cesarean to unassisted homebirth, depending on a variety of factors. There is less of an expectation for women to follow evidence based practices, but I hope there is an expectation for health care practitioners to do so.
Malpractice is a commonly quoted boogeyman as a reason to intervene, but research also indicates that using evidence based algorithms for interventions can lower cesarean rates and malpractice rates simultaneously. Many studies show an association between high malpractice payouts and premiums and high cesarean rates, but the casuality is missing in that association. What if it is the other way around? Interventions chosen despite evidence against their usage in many situations may arguably cause more malpractice suits and higher premiums. Causality is hard to prove in complex situations like this, but it can easily be argued that this association may not only be influenced in one direction.

14 responses to “Reply turned post, birth power struggle style”

I know my answer to this question:
“Should a woman need to be so educated on interventions and when they are appropriate that she or someone she brings or hires can run interference to protect her from her paid health care practitioners?”

It is a resounding NO. That just seems silly to me. If I need an advocate in this whole process, then every woman should get one, not just those who are rich enough and/or have had the time to research the situation and conclude that she needs an advocate.

I also think its just crazy to expect a woman in labor to be able to effectively advocate for herself. I had an epidural and wasn’t in a lot of pain. But I still wasn’t thinking like I normally do. I think it is the job of the medical professionals attending the birth to help me make good, evidence-based decisions at that point.

I should also clarify- I don’t think my husband thinks a C-section is safer for the mother and baby. He just thinks it is safer for the hospital and doctor, in that they can argue they did everything medically possible to ensure a good outcome. I don’t know if I agree with that opinion. As you say, there are risks with C-sections, and why couldn’t a woman sue after a “bad” C-section if she thinks that a simple change in position would have prevented the surgery? I tend to think something more subtle than fear of lawsuits is at work. But I don’t know- it will be interesting to see what your research discovers.

Thank you. correlation does not causation make…..I think many folks lose sight of this. And I think it is way too much to ask laboring women to educate themselves in every aspect of every intervention. I have enough trouble keeping up!

It was interesting to read the original post and to read your response. I have been thinking lately about the question being raised about whether you should need to hire or bring an outside individual to advocate for you during your labor/delivery. My answer would be a simple no, but then I start thinking about all the other areas of health care. How often do we read that people who are being treated for chronic or complicated medical conditions should bring a second person with them to the doctor’s office to listen and take notes? And that in the hospital, you should try to have a friend or family member with you, advocating for you and keeping an eye on whether you’re getting the correct medications etc.? When my grandmother goes into the hospital there is always someone with her – preferably one of her children or in-laws who is a health care professional – to keep an eye on medications, translate what the doctors are saying, and advocate for her. She could have had (possibly unnecessary or unhelpful) surgery several times over by now if not for family members putting the brakes on and asking for a closer review. My mother, who is a physician, often says after one of those hospital stays “Everyone should have someone to advocate for them in the hospital”. Medication errors, wrong treatments, too much treatment, too little…it’s not just obstetrics that’s calling for patient advocates. So then what does that say about our whole medical system? Is it possible to deliver high-quality care with true informed consent to ALL patients (not just women in labor) to the point where no one needs an advocate? If it is possible, is it feasible with the resources available? And if not, where does that leave us?

Anyway, it’s late and I might be making less sense than I should. I guess I’m just trying to say that yes, it is screwed up when women need to bring someone to protect them in the hospital, and there are some distinct needs for protection in labor that are different from other reasons to be in the hospital (like the fact that you’re not sick). But part of it may also be a symptom of a medical system that in standardizing and implementing generally effective care tends to let many smaller pieces slip through the cracks. I am honestly wondering, is it possible to retain the good things about that system and eliminate the bad?

No, you’re making a lot of sense. My dad was in and out of hospitals for the last 12 years of his life due to a medical error, and had to be advocated for almost daily whenever he was in the hospital. It is a shame that medical errors are as prevalent as they are, and that care is not more organized and patient-friendly.

However, I think obstetrics is a beast all of its own. There is a different between a practice that is a medical error and one that is harmful, yet is part of standard practice. Interventions like routine liberal oxytocin administration, early amniotomy, elective cesarean section, cesarean section instead of VBAC attempt, lack of availability of doulas, lack of use of upright positions in the second stage, coached Valsalva pushing, liberal episiotomy usage, continuous external fetal monitoring, denial of nutrition, discouraging of ambulation, inducing at early gestational age on an unripe cervix or for suspected simple macrosomia (am I missing any?) are all routine, systemic practices in obstetrics. They are all associated with worse outcomes or questionably supported.

So, yes, our medical system is broken. But, I think obstetrics is pulverized.

I largely agree with you on the extra-brokenness of the obstetric system, illustrated by its reputation as one of the least evidence-based specialties. Cloud’s story illustrates this as she’s pointing out that in four hours, not one person ever thought to suggest a different position. I guess I’m just thinking, even if someone had suggested it – even if we had fixed obstetrics to be regularly-broken instead of extra-broken – would an advocate never have been necessary for any other reasons? I honestly don’t know. I know a few insurance plans will cover doulas, but the general patient-advocate role – no, and that’s why I’m wondering above whether we could ever afford a system where everyone gets a professional advocate, provided by insurance and/or the hospital.

“Should a woman need to be so educated on interventions and when they are appropriate that she or someone she brings or hires can run interference to protect her from her paid health care practitioners?” – I wish that weren’t the feeling, but on some days I feel that everyone needs an educated advocate when being hospitalized for any reason.

On the flipside of feeling like one needs to do a lot of self-education and plan for an advocate, I can’t personally relate to the blind trust I feel that some women have in their ob/gyns (or other providers), and it seems like women never want to hear that theirs might not have been following the evidence, even if there was a bad or unnecessary outcome. It seems like there is a fair bit of defensiveness about that, a “well, my Doctor did this and because he did it and I trust him, it must have been the best/only choice, and I don’t want to even think other possibilities might exist. Everything happened exactly as it should have.” Do you have any thoughts on why that is (or if I’m imagining it, and am too cynical)?

Well, that’s one of the reasons I want to talk to women, all kinds of women. I want to talk to the ones who don’t want to learn about their pregnancies, labors and deliveries, like my sister in laws. Both are educated and intelligent, and blindly accepted every intervention under the sun. I tried to gently approach some issues with them, but early in their pregnancy learned this was unwelcome and seriously rocking their vision of birth.

ACOG has a recent position statement about elective surgery that discourages a physician/patient interaction that is based on paternalism. I think some patients want a paternalistic physician. Challenging the physician’s authority, hospital policies or the current state of obstetrical practice shakes the framework on which some women stake their security.

Maybe it would be helpful to give you all a little more background on me. I have a PhD in biochemistry and am usually the type of patient who is very involved in making decisions about my treatment. I pick doctors who are OK with that.

I have a pretty good relationship with my ob/gyn and his nurse practitioner- the two people who oversaw my prenatal care. I think the hospital I used does a good job of pre-birth education, too. I certainly had learned about using different labor positions and had even practiced getting into them during class.

So what went “wrong” in the birth room? I just forgot that I should change positions.

I think several things contributed to that- first of all, being in labor for the birth of your first child is a pretty emotionally charged time, and I just wasn’t thinking like I usually do. I think my husband is used to having me advocate for myself and wasn’t really prepared for the idea that he should do it for me. Also, he was also probably not thinking like he usually does.

Second, there are A LOT of things to learn about when you’re pregnant, and a lot of societal cues about pregnancy, birth, and motherhood to sort through. I was surprised by how hard I found it to make decisions about my pregnancy, birth options, and even about how to parent my baby once she was born. It is completely unlike making decisions about managing my (mild) asthma, for instance. I think part of that is because no one else really cares how I choose to manage my asthma. A lot of people seem to feel like they have a right to comment on my decisions during pregnancy and as a mother.

@Rachel, Rebecca- I can see your point about having an advocate for all hospital stays. However, I am nervous about that becoming the expectation, because I think that it sets up a system that is inherently skewed to provide better care to people with more money. If I need an advocate, then EVERYONE needs an advocate, and insurance should pay for one.

We still haven’t decided what we’ll do this time around. I’m reading some more books and papers, and considering whether we’ll hire a doula.